Kadima Rehabilitation & Nursing At Latrobe
Inspection history, citations, penalties and survey trends for this long-term care facility in Latrobe, Pennsylvania.
- Location
- 576 Fred Rogers Drive, Latrobe, Pennsylvania 15650
- CMS Provider Number
- 395892
- Inspections on file
- 43
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Kadima Rehabilitation & Nursing At Latrobe during CMS and state inspections, most recent first.
Failure to Provide Scheduled Showers: A resident with dementia who required staff help with bathing was scheduled for showers twice weekly, but review of ADL/bathing records showed multiple missed or undocumented shower opportunities. Instead, the record showed bed baths on several dates and other entries marked N/A without evidence the resident was offered, provided, or refused a shower. The resident said he was not always offered showers, and the DON confirmed there was no documented evidence the shower schedule was followed.
Failure to Flush Central Venous Catheters During IV Antibiotic Administration: The facility did not document flushing of central venous catheters before and after IV antibiotic administration for three residents. A resident recovering from joint replacement surgery received IV Cefazolin via PICC, and two residents with pneumonia received IV Vancomycin via midline catheters, but MAR review showed no evidence of flushing as required by policy. The DON confirmed the missing documentation.
A resident who was moderately cognitively impaired and needed staff help with daily care was observed being pushed from the shower room to his room in a wheeled shower chair with only a folded sheet across his lap, leaving his chest, back, upper thighs, and legs exposed. Staff and the NHA confirmed the resident should not have been transferred through the hall in that manner and that his dignity was not maintained.
A facility failed to maintain clean HVAC units and a resident's wheelchair. Surveyors observed thick dust on multiple ceiling HVAC filters, with one unit also rattling and another having filters hanging out of the unit. A resident's wheelchair was also found with a large amount of removable dust on the frame and backrest, and staff interviews showed unclear responsibility for keeping wheelchairs clean.
Care plans were not kept current for two residents. One resident’s code status changed from DNR back to Full Code after a change in condition and a signed POLST, but the care plan still listed DNR. Another resident’s care plan included 15-minute checks and 1:1 observation for dementia-related behaviors, but there was no documentation those interventions were being done, and the DON confirmed they had stopped even though the care plan was not revised.
Failure to Follow Ordered Bowel Protocol: A resident who was cognitively impaired and frequently incontinent of bowel movements had physician-ordered bowel interventions, including prune juice, MOM, bisacodyl suppository, and a Fleets enema, but review of bowel records and MARs showed no documented bowel movement over multiple periods and that staff did not initiate or follow the ordered bowel protocol. The DON confirmed the orders were not followed.
A resident who was cognitively impaired and required extensive staff assistance was observed being pushed from the room into the hallway with the legs dangling and no leg rests on the wheelchair. An NA said she could not find the leg rests in the resident’s closet, and the DON confirmed the resident should have had leg rests while being transported.
Medication administration errors caused the facility to exceed the allowed error rate. An LPN crushed medications that were listed as not to be crushed, including metformin ER, propranolol HCL, and Myrbetriq ER, for one resident, and another LPN administered Breo Ellipta to a resident without offering water or instructing the resident to rinse and spit afterward as required by policy and the manufacturer’s directions.
Improper Crushing of Medications: An LPN crushed and administered medications for a resident with cognitive impairment and diagnoses including diabetes, overactive bladder, and heart disease, even though the facility’s list identified propranolol HCL, metformin HCL ER, and Myrbetriq ER as medications not to be crushed. The LPN said she was unaware the meds should not be crushed, and the DON stated the pharmacy does not label them do not crush until the physician orders that.
QAPI failed to correct recurring deficiencies identified in prior survey plans of correction. The current survey again found problems with quality care, IV fluids, and drug labeling, despite prior audits and reporting to the QAPI committee for review. The cited issues were tied to repeated failures in MDS accuracy, care planning, and overall quality of care.
Nursing staff failed to document administration of controlled medications after signing them out for three cognitively intact residents with pain-related conditions. Facility policy required immediate recording of each administered dose on the MAR. For one resident with chronic back pain, Percocet doses were signed out on two occasions without any MAR or clinical record entries. For another resident on hospice with spinal stenosis and diabetic neuropathy, multiple Morphine doses were signed out with no corresponding documentation of administration. For a third resident with occasional pain on PRN opioids, Percocet doses were also signed out on two occasions without any MAR or clinical record entries. The DON confirmed that there was no documentation showing these signed-out narcotic doses were actually administered.
Two residents requiring colostomy care did not receive proper services as required. One resident with paraplegia had no documented evidence of colostomy care being provided despite care plan instructions. Another resident had orders for ostomy care every shift, but there were no specific orders or care plan for changing or emptying the colostomy appliance, and staff only emptied the bag after being prompted by the resident. The DON confirmed the lack of necessary orders and care planning.
A resident receiving IV antibiotics via a PICC line was found with a dressing that had not been changed according to facility policy, which requires weekly changes. The dressing remained in place for eight days, and the DON confirmed it was overdue, demonstrating a lapse in required PICC line care.
A resident with end-stage renal disease who required hemodialysis did not have documented communication between the facility and the dialysis center regarding their health status before and after dialysis sessions, as required by facility policy and physician orders. The DON confirmed the absence of this documentation.
The facility did not maintain sanitary conditions for ice storage, as the ice machine drain was directly connected to a PVC pipe leading to a bucket of stagnant water without the required air gap. The Maintenance Director confirmed the absence of the air gap and noted that a malfunctioning sump pump caused the bucket to fill with stagnant water.
The facility did not obtain or document reference checks for five newly hired staff members, including nurse aides, an LPN, an RN, and the Maintenance Director, as required by facility policy. This was confirmed through review of personnel files and staff interviews.
A resident was discharged to a senior living community, but the required physician discharge summary was not completed. Review of the clinical record and staff interviews confirmed the absence of this documentation at the time of survey.
A resident with diabetes and orders for blood pressure medications did not have required blood pressure or heart rate checks documented prior to administration of amlodipine, clonidine, or metoprolol. Facility policy and physician's orders required these assessments, but review of the E-MAR and confirmation from the DON showed they were not performed or documented.
A resident with diabetes returned from the hospital with physician orders for specific insulin administration and blood glucose monitoring. Facility staff failed to check the resident's blood glucose and did not administer the ordered insulin doses. The resident reported symptoms and a high glucose reading, and the DON confirmed the required care was not provided.
Three opened bottles of Aplisol solution in a medication room refrigerator were found without labels indicating the date they were opened, contrary to facility policy and manufacturer instructions. The ADON confirmed that these bottles should have been dated upon opening.
A resident receiving hospice care, who was cognitively impaired and dependent on staff, did not have updated hospice nurse aide or RN charting in their clinical record as required by facility policy. The DON confirmed the absence of this documentation, despite an active hospice care plan and physician order.
The QAPI committee did not effectively implement plans of correction for previously cited deficiencies, resulting in repeated failures to comply with regulations on abuse policies, quality of care, medication storage, and food sanitation. Despite conducting audits and reviewing results, the committee was ineffective in ensuring ongoing compliance in these areas.
Surveyors identified multiple lapses in infection prevention and control, including an LPN failing to perform hand hygiene after glove removal, lack of Enhanced Barrier Precautions for a resident with an indwelling catheter, and improper handwashing technique by another LPN after obtaining a blood sugar reading.
A resident with diabetes and other medical conditions did not have blood sugar monitoring documented as required by physician orders, despite orders for scheduled and as-needed insulin administration. The DON confirmed the absence of documentation for blood sugar monitoring.
The facility did not update care plans to reflect changes in care needs for several residents, including the discontinuation of foley catheters, antibiotics, and anticoagulant medications. Care plans continued to list outdated interventions or therapies, as confirmed by review of clinical records and interviews with the DON.
Staff did not document obtaining blood pressure and heart rate before administering Metoprolol to two residents with hypertension, as required by physician orders. The medication was given over multiple days without evidence that the necessary vital signs were checked prior to administration, as confirmed by the DON.
The facility did not maintain sanitary conditions for the ice machine near the kitchen, as the drain pipe was found submerged in stagnant water within a bath basin and lacked the required air gap, contrary to manufacturer instructions.
A resident who was cognitively intact and able to communicate was not kept informed about his discharge plans. Although staff communicated with the resident's family regarding discharge arrangements, they did not provide the resident with updates or document these communications in the medical record.
A registered nurse was allowed to begin employment before the required license check was completed, contrary to facility policy that mandates background and license verification prior to hire. This was confirmed by review of the nurse's personnel file and staff interview.
The facility did not accurately complete MDS assessments for five residents, failing to document the administration of anti-platelet, anti-anxiety, and antibiotic medications as indicated in physician orders and medication records. These discrepancies were confirmed by review of clinical documentation and staff interviews.
The facility did not complete required safety assessments for a resident using siderails and two residents using air mattresses. One cognitively intact resident with a knee prosthesis infection was observed using bilateral siderails without a fully completed assessment. Two other residents, one with chronic DVT and another with cerebral palsy and cognitive impairment, were using air mattresses without documented safety assessments. The DON confirmed that these assessments were not completed.
Two residents with indwelling urinary catheters did not have their urinary output consistently documented as required by physician orders and care plans. Record reviews showed multiple missed entries across several shifts, and the DON confirmed the lack of documentation.
The facility did not keep the posted nurse staffing information up to date, as the information displayed at the main entrance was not current and was confirmed by the administrator.
A controlled medication, Ativan, was found stored in a medication refrigerator with other non-controlled medications, rather than in a separately locked, permanently affixed container as required by facility policy. An LPN and the DON confirmed that the Ativan was not properly secured according to double-lock security protocols.
The facility did not ensure clinical records were accurately maintained for two residents, including missing documentation of pain assessment and dental referral for a resident with dental issues, lack of psychiatric follow-up records for a resident with schizophrenia, and absence of discharge planning notes for a cognitively intact resident. These omissions resulted in incomplete medical records as required by professional standards.
The QAPI committee did not effectively implement or follow through on plans of correction for previously identified deficiencies, resulting in repeated issues with pharmaceutical services, MDS accuracy, care plan timing, quality of care, safety hazards, medication storage, and medical records. Despite audit and reporting processes being outlined, these actions were not successfully executed, leading to ongoing noncompliance.
The facility did not maintain sanitary conditions in three utility rooms, which were filled with soiled linen bags due to non-functional laundry equipment. A laundry attendant confirmed the backlog, and the Regional Clinical Consultant acknowledged the unsanitary state and delayed laundry return to residents.
A resident was injured during transport to dialysis when their wheelchair was not properly secured in the facility's van, leading to a fall and a sternal fracture. The van driver was distracted and failed to lock the wheelchair, resulting in the resident's knees striking their chest. The incident was confirmed by the facility's investigation and the Director of Nursing.
A resident using a wheelchair was injured during transport in a facility van due to improper securing of the wheelchair. The van driver was distracted and failed to lock the wheelchair properly, causing it to tip over. The resident suffered a sternal fracture and required transfer to a trauma center for treatment.
The facility failed to maintain a clean and homelike environment for several residents. A resident's privacy curtain was stained, and multiple rooms had food debris on the floor. Staff interviews confirmed that cleaning schedules were not adhered to, as privacy curtains are washed monthly or during deep cleaning. The Nursing Home Administrator acknowledged the need for cleaning in the affected rooms.
The facility failed to follow physician's orders for medications and treatments for five residents. A resident with a hydrocele did not have a scheduled urology consult. Two residents with hypertension received medication despite blood pressure readings below the ordered threshold, and another resident's blood pressure was not recorded as ordered. Additionally, wound care treatments for two residents were not documented as administered. The DON and wound care staff confirmed these deficiencies.
The facility failed to maintain accountability for controlled medications for three residents. A resident's Oxycodone was signed out but not documented as administered, another resident's entire card of Oxycodone went missing, and a third resident's medications were destroyed without a second nurse present, violating policy.
The facility failed to ensure complete and accurate documentation of care for two residents. One resident's foley catheter care and output were not consistently recorded in the TARs, despite nurse aide documentation indicating completion. Another resident with a Stage 4 pressure ulcer had missing documentation of wound care, although it was confirmed to have been completed. The DON and Infection Control/Wound Care RN acknowledged the documentation errors.
The facility failed to follow proper infection control practices, including not disinfecting a glucometer between residents, inadequate hand hygiene during wound care, lack of Enhanced Barrier Precautions for a resident with an indwelling catheter, and improper handling of oxygen tubing for a resident with respiratory issues. These actions were contrary to facility policies and CDC guidelines.
A resident with impaired cognition and an indwelling urinary catheter was observed with their urinary drainage bag visible from the door and without a privacy cover. Staff interviews confirmed the lack of a privacy cover, which compromised the resident's dignity.
The facility did not complete comprehensive MDS assessments within the required timeframe for three residents. An annual MDS assessment must be completed no later than 14 days after the ARD. One resident's assessment was completed 16 days after the ARD, another's 19 days after, and a third's 15 days after. These delays were confirmed by the DON.
The facility failed to complete Quarterly MDS assessments within the required timeframe for 17 residents. According to the RAI User's Manual, assessments are due every 92 days, but several were completed between two to 51 days late. The DON confirmed the non-compliance, indicating a systemic issue in adhering to the mandated schedule.
The facility failed to submit MDS assessments to the CMS QIES ASAP System within the required 14-day timeframe for several residents. Despite varying completion dates, all delayed submissions occurred on the same date, indicating a systemic issue. The DON confirmed these delays during an interview.
The facility failed to accurately complete MDS assessments for two residents. One resident's hospice services were not correctly documented, and another resident's injection and insulin administration days were inaccurately recorded. These discrepancies were confirmed by the DON.
The facility failed to develop and implement individualized care plans for three residents, including one with high blood pressure, another requiring oxygen therapy, and a third with PTSD. The absence of care plans for these residents' specific needs was confirmed by the DON.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to ensure that a resident who required staff assistance with bathing was provided showers as scheduled. Resident 72 had a quarterly MDS assessment indicating he could make himself understood and understand others, required assistance from staff for daily care needs including showering, and had a diagnosis of dementia. His care plan directed that he receive showers twice weekly on daylight shift, and the facility policy for flow of care stated that baths and showers were to be provided on evening shift as part of resident care and documented on the ADL flow records. Review of bathing documentation for December 2025 through March 2026 showed multiple instances where the resident received bed baths, but there was no evidence he was offered or refused a shower on those dates. Additional entries documented showers as not applicable on several dates, again without evidence that a shower was offered, provided, or refused. On March 7, there was no documentation that a shower was offered, provided, or refused. The resident stated he was not always offered a shower twice a week and did not recall refusing showers. The DON confirmed there was no documented evidence that the resident was offered or provided showers according to his care schedule during the dates reviewed.
Failure to Flush Central Venous Catheters During IV Antibiotic Administration
Penalty
Summary
The facility failed to ensure that central venous catheters were flushed before and after IV medication administration for three residents. The facility policy dated August 13, 2025, required central venous (midline) catheters to be flushed before and after use for medication administration and documented in the medical record. For Resident 64, who was cognitively intact and receiving aftercare following joint replacement surgery, physician orders included IV Cefazolin every eight hours for six weeks, but the MAR for March 2026 showed the antibiotic was administered from March 14 through March 19 with no documented evidence that the PICC was flushed before and after administration. The DON confirmed there was no documented evidence of flushing for this resident. Resident 91, who was cognitively intact and independent with daily care needs, had physician orders for IV Vancomycin once daily for pneumonia, but review of the February and March 2026 MARs showed no documented evidence that the midline catheter was flushed before and after antibiotic administration. Resident 107, a new admission who was cognitively intact and required assistance with daily care needs and had pneumonia, also had physician orders for IV Vancomycin once daily, and review of the March 2026 MAR showed no documented evidence that the midline catheter was flushed before and after administration. The DON confirmed there was no documented evidence that Residents 91 and 107's midline catheters were flushed before and after medication administration.
Resident Exposed During Hallway Transfer
Penalty
Summary
The facility failed to maintain resident dignity for one resident who was moderately cognitively impaired, sometimes understood and was sometimes understood by others, and required staff assistance with daily care needs. After showering, the resident was observed being pushed in a wheeled shower chair approximately 30 feet from the shower room down the first-floor hall to his room with only a folded sheet/blanket across his lap, while his chest, back, upper thighs, and legs were exposed. Staff interviews confirmed that the resident should not have been transferred through the hall with only a folded sheet on his lap and that most of his body was exposed. The Nursing Home Administrator also stated that staff should have provided for the resident's dignity during the transfer and did not.
Dirty HVAC Units and Wheelchair
Penalty
Summary
The facility failed to provide a clean and homelike environment by not maintaining ceiling HVAC units and by not providing a clean wheelchair for one resident. Observations on March 16, 2026 showed the East Hall HVAC unit had a thick layer of dust on the filters and was making a rattling noise. The [NAME] 1 hall HVAC unit also had a thick layer of dust on the filters, and the [NAME] 2 hall HVAC unit had a thick layer of dust on the filters with the filters hanging out of the unit. The facility policy titled resident rights stated that the resident has a right to a safe, clean, comfortable and homelike environment. Resident 5's wheelchair was observed on March 19, 2026 with a large amount of brownish/white removable dust on the metal frame and the top of the back rest cushion. Interviews with staff showed confusion about who was responsible for cleaning wheelchairs, with one maintenance assistant stating he thought housekeeping cleaned them, a nurse aide confirming the wheelchair was dirty and should have been cleaned, and a housekeeping employee stating she would clean a wheelchair only if she saw it during deep cleaning. The Assistant Director of Nursing confirmed that maintenance and housekeeping share responsibility for wheelchair cleanliness and stated the dust, dirt, and debris on Resident 5's wheelchair should not have been there.
Care plans not updated to reflect residents’ changed needs
Penalty
Summary
The facility failed to keep care plans updated to reflect changes in residents’ care needs for two residents. For one resident, the quarterly MDS showed moderate cognitive impairment, extensive assistance needs, and diagnoses including cerebral palsy and intellectual disorders. Her record showed she was Full Code from admission until her code status changed to DNR, then she developed shortness of breath, congestion, and an increased heart rate, and her mother verbally changed her status back to Full Code. A POLST was signed by the nurse practitioner and the resident’s mother indicating Full Code, and physician orders also reflected Full Code, but the resident’s current care plan still listed her code status as DNR. Staff interviews confirmed the care plan was not updated when her health status changed and/or when the POLST was signed, and the DON confirmed it should have been updated to reflect the current Full Code status. For the second resident, the quarterly MDS showed cognitive impairment, need for assistance with daily care, and a diagnosis of dementia. The care plan included antipsychotic medication for dementia with behaviors, an intervention for 15-minute checks related to physical aggression, and another intervention for one-on-one observation related to increased anxiety. The record contained no documented evidence that the 15-minute checks or one-on-one observation were being completed. The DON confirmed that the resident was no longer receiving the 15-minute checks or one-on-one observation, but the care plan was not revised when those interventions were resolved and should have been.
Failure to Follow Ordered Bowel Protocol
Penalty
Summary
The facility failed to ensure that bowel protocols were followed as ordered for one resident who was cognitively impaired and frequently incontinent of bowel movements. Physician orders dated January 2, 2026 directed staff to give 4 ounces of prune juice as needed for no bowel movement in two days and every shift until a bowel movement occurred, 30 milliliters of Milk of Magnesia as needed for no bowel movements for three days, a 10 milligram bisacodyl suppository rectally as needed for no bowel movement for four days, and a Fleets enema rectally as needed if there was still no bowel movement 12 hours after the suppository. Review of the resident’s bowel records for February 2026 showed no documented bowel movement from February 2 through 6 and February 15 through 20, 2026, and review of the MARs showed staff did not initiate or follow the ordered bowel protocol during those periods. The DON confirmed that the physician’s bowel medication orders were not followed.
Wheelchair Transport Without Leg Rests
Penalty
Summary
The facility failed to ensure that the resident environment remained as free of accident hazards as possible when Resident 42 was transported without leg rests on the wheelchair. Resident 42’s admission MDS dated December 12, 2025, showed that the resident was cognitively impaired and required extensive assistance from staff for care. During observation on March 18, 2026 at 9:30 a.m., a nurse aide was seen pushing Resident 42 from the resident’s room into the hallway with the resident’s legs dangling and no leg rests on the chair. When interviewed at that time, the nurse aide stated she pushed the resident without leg rests because she could not find any in the resident’s closet. The DON later confirmed that Resident 42 should have had leg rests on the wheelchair while being transported.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
Medication administration errors were observed that contributed to the facility failing to maintain a medication error rate of less than five percent. The facility’s policy required medications to be administered in accordance with good nursing principles and practices, and its list of medications not to be crushed identified metformin ER, Myrbetriq ER, and propranolol HCL as medications that were not to be crushed. For Resident 32, physician orders included propranolol HCL 20 mg three times daily, metformin ER 500 mg twice daily, and Myrbetriq 25 mg daily. During medication administration observation, an LPN prepared these medications by crushing them and administered the crushed medications to the resident. The LPN stated she was unaware that propranolol HCL, metformin ER, and Myrbetriq ER should not be crushed, and the DON stated the nurse should not have crushed them. A separate medication administration observation involved Resident 88, whose physician order included Breo Ellipta 100-25 mcg/act inhalation powder once daily. Facility policy for steroid inhalers directed staff to provide water and instruct the resident to rinse and spit after use, and the manufacturer’s prescribing information for Breo Ellipta stated the user should rinse the mouth with water without swallowing after use to reduce the chance of thrush. During the observed administration, an LPN gave the Breo Ellipta inhaler but did not offer the resident water or instruct him to rinse and spit afterward. The LPN acknowledged she did not offer the rinse, and the DON stated she should have offered it.
Improper Crushing of Medications
Penalty
Summary
Medication administration was not carried out in accordance with the facility’s list of medications that are not to be crushed for one resident. The resident’s quarterly MDS showed cognitive impairment, dependence on staff for all daily care needs, and diagnoses of diabetes, overactive bladder, and heart disease. Physician orders included propranolol HCL 20 mg three times daily, metformin HCL ER 500 mg twice daily, and Myrbetriq ER 25 mg daily, and the facility’s list identified propranolol HCL, metformin HCL ER, and Myrbetriq ER as medications not to be crushed. During observed medication administration, an LPN prepared the resident’s propranolol HCL, metformin HCL ER, and Myrbetriq ER by crushing them and then administered the crushed medications. In interview, the LPN stated she was unaware that these medications should not be crushed and said the medication packages did not indicate do not crush. The DON stated the medication package should have said do not crush, but the pharmacy does not label the medications do not crush until the physician orders that.
QAPI Committee Failed to Address Repeated Quality Deficiencies
Penalty
Summary
The facility’s QAPI committee failed to correct recurring quality deficiencies identified in prior and current surveys. The report states that the facility had previously developed plans of correction after an annual survey ending December 10, 2025, including quality assurance systems intended to maintain compliance with cited nursing home regulations, but the current survey ending March 19, 2026, again found repeated deficiencies related to quality care, IV fluids, and labeling drugs. The facility’s prior plans of correction for inaccurate MDS assessments, development of care plans, and quality of care each called for audits and reporting the results to the QAPI committee for review. Despite those stated plans, the current survey found that the QAPI committee failed to successfully implement the plan to ensure quality care was provided, failed to ensure IV fluids were administered appropriately, and failed to ensure drugs were labeled appropriately. The cited deficiencies were referenced under F684, F694, and F761, along with 28 Pa. Code 201.14(a) and 28 Pa. Code 201.18(e)(1).
Lack of Documentation for Signed-Out Controlled Medications
Penalty
Summary
The deficiency involves the facility’s failure to maintain accountability and documentation for controlled medications for three cognitively intact residents with pain-related conditions. Facility policy dated May 14, 2025, required nursing staff to record and sign the medication, dosage, and time of administration on each resident’s medication record immediately after administration. For one resident with chronic back pain related to spinal stenosis and discitis, physician orders dated October 20, 2025, prescribed Percocet 5-325 mg every six hours as needed. The controlled drug record for October 2025 showed Percocet tablets signed out on October 24 at 3:30 p.m. and October 25 at 9:00 a.m., but there was no corresponding documentation on the MAR or elsewhere in the clinical record that these doses were administered. A second resident, cognitively intact with spinal stenosis, diabetic neuropathy, recent hospice admission, and an opioid regimen, had a physician’s order dated January 10, 2026, for Morphine 10 mg sublingual every two hours as needed for pain or respiratory distress. The January 2026 controlled drug record showed Morphine 10 mg doses signed out on January 10 at 8:00 a.m., 12:00 p.m., and 4:00 p.m., with no documented evidence on the MAR or in the clinical record that these doses were given. A third cognitively intact resident with occasional pain and on routine and PRN pain medications, including an opioid, had an order dated December 29, 2025, for Percocet 5-325 mg every 12 hours as needed. The controlled drug record for late December 2025 and January 2026 showed Percocet tablets signed out on December 28 at 6:15 p.m. and January 5 at 10:30 a.m., again without documentation in the MAR or clinical record that the doses were administered. In an interview on January 14, 2026, at 3:57 p.m., the DON confirmed there was no documented evidence in the three residents’ records that the signed-out narcotic doses were administered at the recorded dates and times.
Failure to Provide and Document Colostomy Care for Two Residents
Penalty
Summary
The facility failed to provide proper colostomy care for two residents as required. For one resident with paraplegia and a colostomy, the care plan specified that staff were to change the colostomy appliance as necessary. However, a review of the clinical records, physician's orders, and treatment administration records revealed no documented evidence that colostomy care was being provided. This was confirmed by the Nursing Home Administrator during an interview. For another resident with a colostomy, physician's orders indicated that ostomy care was to be provided every shift. Observations confirmed the presence of a colostomy bag, and the resident reported that staff usually emptied the bag at least once per shift, but sometimes only after prompting. There were no physician's orders for changing or emptying the colostomy appliance, and no care plan was in place for the resident's colostomy. The DON confirmed the absence of both physician's orders and a care plan for colostomy care.
Failure to Timely Change PICC Line Dressing
Penalty
Summary
The facility failed to provide adequate care and maintenance for a peripherally inserted central catheter (PICC) for one resident. According to facility policy, PICC dressings are to be changed 24 hours after insertion and then weekly or as needed. A resident with moderate cognitive impairment, requiring staff assistance for daily care, and receiving IV antibiotics for MRSA, was observed with a PICC line dressing that had not been changed for eight days. The dressing was dated October 29, 2025, despite the requirement for a change by November 5, 2025. The Director of Nursing confirmed that the dressing change was overdue, indicating non-compliance with established protocols for PICC line care.
Failure to Document and Communicate Resident Status Before and After Dialysis
Penalty
Summary
The facility failed to ensure proper communication regarding a resident's health status or changes in condition before and after dialysis treatments. According to facility policy, residents receiving dialysis are to be monitored, and relevant medical information from the dialysis provider must be maintained in the resident's medical record. If such information is not received upon the resident's return, the facility is required to contact the dialysis provider to obtain it. For one resident with end-stage renal disease who was cognitively intact and dependent on hemodialysis, physician orders and the care plan specified that vital signs and weight were to be recorded before dialysis and that open communication with the dialysis center was necessary. However, review of the resident's clinical record and dialysis binder revealed no documented evidence of communication between the facility and the dialysis center regarding the resident's health status before and after dialysis on multiple occasions. Nursing notes and the medication administration record confirmed that the resident attended dialysis on several dates, but there was no documentation of the required communication. The Director of Nursing confirmed that such documentation was missing and acknowledged that it should have been present.
Ice Machine Lacked Required Air Gap, Resulting in Unsanitary Storage Conditions
Penalty
Summary
The facility failed to ensure that ice was stored under sanitary conditions in the main dining room. According to the facility's policy, there should be an air gap between the ice machine drain and the drainage pipe. However, observations revealed that the ice machine drain was inserted directly into a PVC pipe, which led to a bucket under the sink that was full of stagnant water. There was no air gap between the ice machine drain pipe and the PVC pipe, nor between the opposite end of the PVC pipe and the bucket. The Maintenance Director confirmed that the sump pump was not functioning properly, resulting in the accumulation of stagnant water in the bucket and the absence of the required air gap.
Failure to Obtain Reference Checks for New Hires
Penalty
Summary
The facility failed to obtain and document reference checks for five newly hired employees, including two nurse aides, an LPN, an RN, and the Maintenance Director. According to the facility's policy dated May 14, 2025, all new hires are required to have verified references documented in their personnel files prior to starting employment. However, a review of the personnel files for these five staff members revealed no evidence that reference checks from previous employers were obtained before their start dates. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged the absence of documented reference checks for the identified staff members. The lack of compliance with the facility's own policy and state regulations regarding pre-employment screening was identified through review of facility policies, personnel records, and staff interviews.
Physician Discharge Summary Not Completed for Discharged Resident
Penalty
Summary
The facility failed to ensure that a physician completed a discharge summary for one resident who was discharged to a senior living community. Clinical record review showed that the resident was admitted to the facility and later discharged, as documented in a nursing note. However, at the time of the survey, there was no evidence in the clinical record that a physician discharge summary had been completed for this resident. This was confirmed during an interview with the Assistant Director of Nursing, who acknowledged that the required discharge summary was not completed by the physician.
Failure to Assess and Document Vital Signs Prior to Medication Administration
Penalty
Summary
The facility failed to follow physician's orders regarding medication administration for one resident. According to the facility's medication administration policy, medications must be given in accordance with written physician orders, and documentation in the electronic medication administration record (E-MAR) should include vital signs such as blood pressure or heart rate when appropriate. For a resident who was cognitively intact, independent with personal care, and had a diagnosis of diabetes, physician's orders specified that amlodipine should be held for a systolic blood pressure (SBP) less than 120, clonidine should be held for SBP less than 120 or heart rate less than 55, and metoprolol should be held for SBP less than 100 or heart rate less than 55. Review of the resident's E-MAR for the relevant months showed no documented evidence that blood pressure or heart rate was checked prior to administering amlodipine, clonidine, or metoprolol as ordered. The Director of Nursing confirmed that these assessments should have been performed and documented prior to medication administration, but they were not. This failure to assess and document vital signs prior to administering these medications constituted a deficiency in following physician's orders and facility policy.
Failure to Administer Insulin and Monitor Blood Glucose as Ordered
Penalty
Summary
A review of facility policy, clinical records, and staff interviews revealed that the facility failed to administer medications as ordered by the physician for one resident. The resident, who was cognitively intact, independent with personal care, and had a diagnosis of diabetes, returned to the facility from the hospital with specific physician orders for insulin aspart (using a sliding scale and fixed doses before meals) and insulin glargine. On the day of return, there was no documented evidence that the resident's blood glucose was checked or that the prescribed insulin doses were administered. The resident reported not having their blood sugar checked and experiencing a headache, with their glucose monitor reading "HI." The physician was notified of the omitted insulin doses and blood glucose checks. The Director of Nursing confirmed that the resident's blood glucose should have been monitored and insulin administered as ordered, but this did not occur upon the resident's return from the hospital.
Failure to Label Opened Multi-Dose Medication Containers
Penalty
Summary
The facility failed to properly label multi-dose containers of medications with the date they were opened in one of the medication rooms. During an observation of the East 1 medication room, three opened and undated bottles of Aplisol solution were found in the medication refrigerator. Facility policy required medications to be stored in accordance with federal and state regulations, including labeling requirements, and the manufacturer's instructions for Aplisol specified that vials in use for more than 30 days should be discarded. The Assistant Director of Nursing confirmed at the time of observation that the opened bottles should have been labeled with the date they were opened.
Failure to Maintain Required Hospice Documentation
Penalty
Summary
The facility failed to ensure that the designated interdisciplinary team member obtained and maintained the required hospice documentation for a resident receiving hospice services. According to facility policy, all hospice assessments, plans of care, progress notes, and services provided must be integrated into the resident's medical record, and nursing staff are responsible for ensuring that current physician orders, progress notes, and hospice documentation are available. For one resident who was cognitively impaired, dependent on staff for daily care, and diagnosed with dementia, there was an active physician's order and care plan for hospice services. However, as of the date of review, there was no documented evidence in either the resident's clinical record or the hospice provider's record that updated hospice nurse aide or registered nurse charting had been obtained or maintained. This was confirmed by the DON, who acknowledged that the required hospice documentation was missing from both records, despite the resident's ongoing hospice care.
QAPI Committee Failed to Address Recurring Deficiencies
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations and did not ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Despite developing plans of correction for previously cited deficiencies, including those related to abuse policies, quality of care, proper storage of medications, and food procurement and sanitation, the QAPI committee did not successfully implement these plans. The current survey identified repeated deficiencies in these same areas, indicating that the committee's actions were ineffective in correcting the issues. Specifically, the facility's plans of correction included conducting audits and reporting the results to the QAPI committee for review. However, the results of the current survey showed that the committee failed to ensure ongoing compliance with regulations regarding abuse policies (F607), quality of care (F684), labeling and storing drugs and biologicals (F761), and food procurement, storage, preparation, and serving under sanitary conditions (F812). The repeated nature of these deficiencies demonstrates that the QAPI committee did not adequately address or resolve the cited issues.
Failure to Adhere to Infection Prevention and Control Practices
Penalty
Summary
The facility failed to maintain professional infection prevention and control practices for three residents. For one resident with moderate cognitive impairment and a PICC line, an LPN entered the room, performed care involving the resident's antibiotic and PICC, removed gloves, and then touched multiple surfaces in the facility without performing hand hygiene. Both the LPN and the Nursing Home Administrator confirmed that hand hygiene should have been performed after glove removal, as required by facility policy. Another resident, who was cognitively impaired and had an indwelling urinary catheter, did not have Enhanced Barrier Precautions (EBP) in place as required. Observations over several days showed that there was no signage or PPE station indicating EBP in or near the resident's room, despite the care plan stating that EBP was in effect. Staff interviews confirmed that EBP should have been implemented for this resident due to the presence of the indwelling catheter, but it was not. A third resident was observed during a medication pass when an LPN obtained a blood sugar reading while wearing gloves. After removing the gloves and washing hands, the LPN turned off the faucet with her clean hand instead of using a paper towel, contrary to facility policy. Both the LPN and the Director of Nursing acknowledged that the correct procedure was not followed. These findings demonstrate lapses in adherence to established infection prevention and control protocols.
Failure to Monitor Blood Sugar per Physician Orders
Penalty
Summary
The facility failed to follow physician's orders for a resident who was cognitively intact and required staff assistance for daily care, with diagnoses including joint prosthesis infection and diabetes mellitus. Physician's orders specified that the resident should receive 15 units of Glargine insulin subcutaneously at bedtime and as needed if blood sugar exceeded 300 mg/dl. However, a review of the Medication Administration Record for June and July 2025 showed no documented evidence that the resident's blood sugar was being monitored as ordered. This was confirmed by the Director of Nursing, who acknowledged the lack of documentation for blood sugar monitoring per physician's orders.
Failure to Update Care Plans Following Changes in Resident Care Needs
Penalty
Summary
The facility failed to ensure that care plans were updated to reflect changes in residents' care needs for five residents. In several cases, care plans continued to list interventions or medications that had been discontinued, such as foley catheters and anticoagulant or antibiotic therapies. For example, one resident's care plan still indicated the presence of a foley catheter after it had been removed and was not re-inserted per physician orders. Another resident's care plan continued to reference anticoagulant therapy even after the medication had been discontinued, and similar discrepancies were found for residents who were no longer receiving antibiotics or anticoagulants, as confirmed by review of physician orders and medication administration records. These deficiencies were confirmed through interviews with the Director of Nursing, who acknowledged that the care plans had not been updated as required. The facility's policy required quarterly reassessment and interdisciplinary review of care plans, but documentation did not show that care plans were revised to reflect significant changes in residents' treatments or conditions. The lack of timely updates to care plans was identified through review of clinical records, policies, and staff interviews.
Failure to Document Required Vital Signs Before Administering Antihypertensive Medication
Penalty
Summary
Staff failed to follow physician's orders for two residents who had diagnoses of hypertension and were prescribed Metoprolol. For both residents, the orders specified that staff were to administer 25 mg of Metoprolol twice daily, but only if the systolic blood pressure was at least 90 mmHg and the heart rate was at least 60 beats per minute. The orders also required staff to hold the medication if these parameters were not met. Review of the Medication Administration Records for both residents showed that Metoprolol was administered twice daily over an 11-day period without documented evidence that blood pressure and heart rate were checked prior to administration. This lack of documentation was confirmed by the Director of Nursing, who acknowledged that there was no evidence staff obtained the required vital signs before giving the medication as ordered.
Ice Machine Drainage Not Maintained in Sanitary Condition
Penalty
Summary
The facility failed to ensure that ice was stored under sanitary conditions for the ice machine located next to the kitchen. Manufacturer's instructions for the ice machine specified that the drain line must have a 1.5-inch drop per 5 feet of run, must not create traps, and that the floor drain must be large enough to accommodate all drainage, with an air gap required between the drain pipe and the basin. However, observations revealed that the ice machine's drain was discharging into a bath basin, with the drain pipe submerged in stagnant water and a small pump moving some water into a nearby sink. There was no air gap present between the drain pipe and the basin, contrary to the manufacturer's instructions.
Failure to Inform Resident of Discharge Plans
Penalty
Summary
The facility failed to ensure that a resident was fully informed and able to participate in decisions regarding his discharge plan. Clinical record review showed that the resident was cognitively intact and able to communicate effectively. Despite this, the resident reported confusion and lack of information about his discharge, stating that he believed he was supposed to go home weeks earlier and that no one had explained the situation to him. The Nursing Home Administrator confirmed that while the Social Worker had communicated with the resident's brother about discharge arrangements, this information was not relayed to the resident nor documented in the medical record.
Failure to Complete License Check Prior to RN Hire
Penalty
Summary
The facility failed to ensure that a license check was obtained prior to the hire of a registered nurse. Review of the personnel file for the registered nurse showed that the individual began employment on March 9, 2025, but the license check was not completed until March 10, 2025, after the start date. The facility's policy required that employment background checks, including license verification, be conducted before an employee's start date to prevent abuse, neglect, or mistreatment of residents. This lapse was confirmed during an interview with the Regional Human Resources Director, who acknowledged that the license check should have been completed prior to the nurse's start date.
Inaccurate MDS Assessments for Medication Administration
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for five residents, as required by the Resident Assessment Instrument (RAI) User's Manual. For several residents, the MDS assessments did not accurately reflect medications administered during the seven-day look-back period. Specifically, residents who received daily doses of aspirin, an anti-platelet medication, were incorrectly coded as not having received anti-platelet therapy. Additionally, a resident who received Clobazam, an anti-anxiety medication, was not coded as having received such medication, and another resident who received triple antibiotic ointment for a wound was not coded as having received an antibiotic medication. These inaccuracies were confirmed through reviews of physician orders, Medication Administration Records (MAR), Treatment Administration Records (TAR), and staff interviews. The discrepancies were identified for residents who had clear documentation of medication administration during the assessment periods, but whose MDS assessments did not reflect this information. The Director of Nursing and the Nursing Home Administrator confirmed the inaccuracies during interviews.
Failure to Complete Safety Assessments for Siderails and Air Mattresses
Penalty
Summary
The facility failed to complete required safety assessments for residents using siderails and air mattresses. For one resident who was cognitively intact and required assistance with daily care due to an infection of a right knee prosthesis, the facility's siderail/assist bar evaluation was not fully completed, specifically omitting the section to determine if siderails or assist bars were indicated. Despite this incomplete assessment, observations confirmed that the resident was using bilateral upper siderails during multiple surveyor visits. The Director of Nursing confirmed that the last two assessments for this resident were not fully completed to identify the need for siderails. Additionally, two other residents who were dependent on staff for personal care and had orders and care plans for the use of air mattresses did not have documented safety assessments for the air mattresses prior to their use. One of these residents was cognitively intact with a diagnosis of chronic deep vein thrombosis, and the other was cognitively impaired with cerebral palsy and at risk for pressure sores. Observations confirmed that both residents were using air mattresses, but there was no evidence of safety assessments being completed. The Director of Nursing acknowledged that air mattress safety assessments were not completed for residents using air mattresses at the time of the survey.
Failure to Document Urinary Catheter Output as Ordered
Penalty
Summary
The facility failed to ensure that urinary output was consistently monitored and documented for two residents with indwelling urinary catheters. For one resident with cognitive impairment and a diagnosis of benign prostatic hyperplasia, the care plan and physician's orders required staff to measure and document urinary catheter output every shift. However, clinical record reviews revealed multiple instances across various shifts where there was no documented evidence of urinary output being recorded, as confirmed by the Director of Nursing. Similarly, another resident with a neurogenic bladder and an indwelling catheter had physician's orders and a care plan directing staff to document urinary output every shift. Review of this resident's records also showed missing documentation of catheter output on several shifts, which was acknowledged by the Director of Nursing. These findings indicate that the facility did not follow physician orders and care plan interventions for monitoring and documenting urinary output for residents with indwelling catheters.
Failure to Post Current Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the nurse staffing information posted at the main entrance was current. On May 17, 2025, an observation revealed that the posted staffing information was dated May 15, 2025, and had not been updated as required. This was confirmed in an interview with the Nursing Home Administrator, who acknowledged that the information displayed was not current.
Controlled Substance Not Properly Secured in Medication Room
Penalty
Summary
A review of facility policies, observations, and staff interviews revealed that a controlled medication, Ativan, was not stored according to the facility's policy and regulatory requirements. The policy required controlled substances to be kept under double-lock security, with access keys for controlled medications being different from those for other medications. During an observation of the East Side medication room, an opened vial of Ativan was found stored in the medication refrigerator alongside non-controlled medications, without being placed in a separately locked, permanently affixed container. An LPN confirmed the absence of a separately locked container for the Ativan, and the DON also confirmed that the medication was not stored as required.
Failure to Maintain Accurate and Complete Clinical Records
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for multiple residents. For one resident with confusion, a nursing note documented dental pain and a missing tooth, but there was no evidence in the clinical record that the resident's pain was assessed or that a dental referral was made, despite the DON later providing a dentist's consult report that should have been included in the record. Another resident with paranoid schizophrenia exhibited ongoing hallucinations and paranoia, but there was no documentation that the psychiatrist was informed of these symptoms or that follow-up psychiatric visits occurred, even though the administrator stated that such visits had taken place. Additionally, a cognitively intact resident was scheduled for discharge, but there was no documentation in the clinical record regarding communication with the resident or his family about discharge plans. The resident expressed confusion about his discharge status, and the administrator confirmed that the social worker had communicated with the resident's brother but had not documented it. These omissions demonstrate a failure to maintain clinical records in accordance with accepted professional standards.
QAPI Committee Failed to Correct Recurring Deficiencies
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct recurring quality deficiencies and did not ensure that plans to improve care and services were effectively implemented. Despite developing plans of correction for deficiencies identified in previous surveys, the committee did not successfully address repeated issues related to pharmaceutical services, inaccurate MDS assessments, care plan timing and revision, quality of care, safety/accident hazards, medication storage, and complete and accurate medical records. The plans of correction included conducting audits and reporting results to the QAPI committee, but these actions were not effectively carried out, as evidenced by the recurrence of the same deficiencies in subsequent surveys. The report specifically notes that deficiencies cited in earlier surveys, such as those ending December 4, 2024, and January 6, 2025, were not resolved, and the same issues were identified again in the most recent survey ending May 20, 2025. The QAPI committee's failure to implement and follow through on their corrective plans resulted in ongoing noncompliance with nursing home regulations across multiple areas of care and facility management.
Failure to Maintain Sanitary Conditions in Utility Rooms
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in three soiled utility rooms, as observed during a survey. The facility's policy on infection control, dated January 2, 2024, emphasizes the importance of preventing healthcare-associated infections and maintaining a sanitary environment. However, observations revealed that the utility rooms were cluttered with soiled linen bags on the floor. An interview with a laundry attendant confirmed that the facility's washer and dryer were not operational, leading to a backlog of laundry. Additionally, the Regional Clinical Consultant acknowledged that the laundry was not being returned to residents in a timely manner and confirmed the unsanitary conditions in the utility rooms.
Neglect During Transportation Leads to Resident Injury
Penalty
Summary
The facility failed to ensure the safety of a resident during transportation to dialysis, resulting in neglect. The resident, who was cognitively intact and used a wheelchair due to limited range of motion and renal failure, was being transported in the facility's van. The facility's transportation policy required that all clients in wheelchairs be secured with wheelchair locks and safety belts. However, during the transport, the van driver did not properly secure the resident's wheelchair, leading to the wheelchair tipping over backwards when the van began to move. The incident occurred when the van was pulling out of the driveway, which had a slight upward grade. The resident's wheelchair was not locked into place, causing the resident to be ejected from the wheelchair. As a result, the resident's knees struck her chest, causing significant sternal pain. Despite the resident's initial refusal for further assessment, she was later sent to the hospital by the dialysis center for evaluation and treatment, where a CT scan revealed a sternal fracture. The facility's investigation confirmed that the van driver was distracted and failed to secure the front of the resident's wheelchair properly. This oversight led to the resident's fall and subsequent injury. The Director of Nursing confirmed the findings, acknowledging that the failure to lock the wheelchair properly resulted in the resident's fall and injury. The incident highlights a breach in the facility's responsibility to protect residents from neglect during transportation, as outlined in their policies.
Failure to Secure Wheelchair Leads to Resident Injury
Penalty
Summary
The facility failed to ensure a safe environment for a resident who used a wheelchair, resulting in an accident during transportation. The resident, who was cognitively intact and required dialysis, was being transported in the facility's van when her wheelchair tipped over backwards. This incident occurred because the van driver did not properly secure the wheelchair, as he was distracted by another passenger's inquiry about a seat belt. The resident reported chest pain after her knees struck her chest during the fall. Following the incident, the resident was sent to a local hospital where a CT scan revealed a sternal fracture. Due to the severity of her condition, she was transferred to a Level 2 trauma center for further treatment, including respiratory support and dialysis. The facility's investigation confirmed that the wheelchair straps were not secured properly, leading to the accident. Interviews with staff corroborated the sequence of events and the oversight in securing the wheelchair.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment in the rooms of five residents. Observations revealed that Resident 6's privacy curtain had multiple colored stains, and the curtain between the resident and her roommate had a reddish-colored stain. The resident was unable to recall when her room was last cleaned. Additionally, the rooms of Residents 8 and 9, as well as Residents 10 and 11, were found to have multiple food debris on the floor between the beds. In the room of Residents 10 and 11, there was also dried fluid from a spill under the foot of the bed by the door. Interviews with staff confirmed the deficiencies. Housekeeper 1 stated that privacy curtains are washed monthly or when a room is deep cleaned, typically when a resident changes rooms or is discharged. The Nursing Home Administrator acknowledged that Resident 6's privacy curtains needed cleaning and should have been changed over the weekend. The administrator also confirmed that the rooms of Residents 8, 9, 10, and 11 required cleaning, indicating a lapse in maintaining a clean environment as per the facility's standards.
Failure to Follow Physician's Orders for Medications and Treatments
Penalty
Summary
The facility failed to ensure that physician's orders for medications and treatments were followed for five residents. Resident 10, who was cognitively impaired and diagnosed with benign prostatic hyperplasia and obstructive uropathy, was ordered to consult urology for a mild hydrocele in the right testicle. However, there was no documented evidence that the urology consult was scheduled as ordered. The Director of Nursing confirmed the absence of documentation for the urology consult. Resident 36, also cognitively impaired and diagnosed with hypertension, was ordered to receive Lopressor with specific instructions to hold the medication if the blood pressure was below 120/80. Despite this, the resident received the medication multiple times when the blood pressure was below the specified threshold. The Director of Nursing confirmed the lack of documentation indicating that the medication was held as ordered. Similarly, Resident 46, who required blood pressure monitoring three times daily, had no documented evidence of blood pressure recordings on several shifts as ordered. Resident 60, with a diagnosis of peripheral vascular disease and a non-pressure chronic ulcer, had orders for specific wound care treatments that were not documented as administered on multiple occasions. The wound nurse confirmed the absence of documentation for these treatments. Resident 87, diagnosed with hidradenitis suppurativa, had orders for wound care treatments that were not documented as completed on several dates. The Infection Control/Wound Care Registered Nurse confirmed the lack of documentation for these treatments.
Controlled Medication Accountability Issues
Penalty
Summary
The facility failed to maintain accountability for controlled medications for three residents. For Resident 56, there was no documented evidence that the signed-out tablets of Oxycodone were administered on specific dates and times, despite being signed out for administration. The Director of Nursing confirmed the lack of documentation for these administrations. Additionally, for Resident 71, an entire card of Oxycodone pills was reported missing. The investigation could not determine who took the narcotic medication, although it was suspected to be an agency nurse, who was subsequently prevented from returning to the facility. For Resident 93, after the resident's death, there was a failure to follow the facility's policy for the destruction of controlled drugs. Licensed Practical Nurse 7 destroyed several pre-filled syringes of Lorazepam and Morphine, as well as tablets of Tramadol, without a second nurse present to verify the destruction, as required by the facility's policy. The Director of Nursing acknowledged that the destruction should have been witnessed by two nurses.
Incomplete and Inaccurate Documentation of Resident Care
Penalty
Summary
The facility failed to ensure that residents' clinical records were complete and accurately documented for two residents. For one resident, physician's orders required foley catheter care and output recording every shift. However, the Treatment Administration Records (TARs) for September, October, and November 2024 showed missing documentation of these tasks on multiple dates, despite nurse aide documentation indicating completion. The Director of Nursing confirmed the lack of documentation by licensed staff on the TARs for the specified dates. Another resident, who had impaired cognition and a Stage 4 pressure ulcer, had physician's orders for daily wound care. The TARs for October and November 2024 revealed missing documentation of wound care on several dates. The Infection Control/Wound Care Registered Nurse confirmed that the wound care was completed as ordered, but there was an error in documentation.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper infection control practices were followed, as evidenced by several deficiencies observed during a survey. A registered nurse did not disinfect a glucometer between blood sugar checks for two residents, despite facility policy and confirmation from the Director of Nursing that the device should be cleaned after each use. Additionally, the nurse did not perform hand hygiene between glove changes during wound care for a resident with a Stage 4 pressure ulcer, contrary to the facility's hand hygiene policy. Another deficiency involved a resident with an indwelling catheter who was supposed to be on Enhanced Barrier Precautions (EBP). There was no signage or PPE station to indicate these precautions were in place, and a nurse aide was unaware of any specific precautions for the resident. The Infection Preventionist confirmed that EBP should have been implemented for this resident, as per the facility's policy and CDC guidelines. Lastly, a resident with a history of acute respiratory failure and pneumonia was observed with oxygen tubing on the floor, which was then placed directly into the resident's nostrils by a registered nurse without replacing it. The Infection Preventionist and Director of Nursing confirmed that the tubing should have been replaced before use. These observations highlight lapses in infection control practices, as outlined in the facility's policies and CDC guidelines.
Failure to Ensure Privacy for Resident with Urinary Catheter
Penalty
Summary
The facility failed to provide dignity for a resident with an indwelling urinary catheter. A quarterly Minimum Data Set (MDS) assessment for the resident revealed impaired cognition and the need for staff assistance with daily care tasks. During an observation, the resident was found lying in bed with the urinary drainage bag hooked to the side of the bed, visible from the door, and without a privacy cover. The yellow urine in the bag was visible. Interviews with a nurse aide and the Director of Nursing confirmed that the resident's urinary drainage bag should have had a privacy cover, which was not in place.
Delayed Completion of MDS Assessments
Penalty
Summary
The facility failed to complete comprehensive annual Minimum Data Set (MDS) assessments within the required timeframe for three residents. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, an annual MDS assessment must be completed no later than 14 calendar days after the assessment reference date (ARD). For Resident 25, the assessment was completed 16 days after the ARD. Resident 84's admission comprehensive MDS assessment was completed 19 days after the ARD, and Resident 92's assessment was completed 15 days after the ARD. These delays were confirmed in an interview with the Director of Nursing.
Failure to Complete Quarterly MDS Assessments on Time
Penalty
Summary
The facility failed to ensure that Quarterly Minimum Data Set (MDS) assessments were completed within the required timeframe for 17 out of 56 residents reviewed. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, a quarterly assessment is due every 92 days, with the completion date being the Assessment Reference Date (ARD) plus 14 days. However, the facility did not adhere to these guidelines, resulting in assessments being completed late for multiple residents. Specific instances of non-compliance include assessments for several residents being completed between two to 51 days late. For example, one resident's assessment was completed 51 days late, while others were completed between two to 27 days late. The Director of Nursing confirmed that these assessments were not completed within the required timeframes, indicating a systemic issue in adhering to the mandated assessment schedule.
Delayed MDS Assessment Submissions
Penalty
Summary
The facility failed to transmit Minimum Data Set (MDS) assessments to the Centers for Medicare and Medicaid Services (CMS) Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) System within the required 14-day timeframe for nine residents. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual mandates that comprehensive MDS assessments be transmitted electronically within 14 days of the Care Plan Completion Date, and all other MDS assessments within 14 days of the MDS Completion Date. However, the facility did not adhere to these guidelines, resulting in delayed submissions for several residents. For instance, the MDS assessment for one resident was completed on August 30, 2024, but was not submitted until October 1, 2024, well past the September 12, 2024 deadline. Similar delays were noted for other residents, with submission dates consistently falling on October 1, 2024, despite varying completion dates and deadlines. An interview with the Director of Nursing confirmed these delays, indicating a systemic issue in the timely electronic transmission of MDS assessments.
Inaccurate MDS Assessments for Hospice and Injection Records
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for two residents. For one resident, the care plan indicated that the resident was receiving hospice services since admission. However, the quarterly MDS assessment did not reflect this, as Section O0100K2 was not checked to indicate hospice services were being received. This discrepancy was confirmed by the Director of Nursing during an interview. For another resident, the MDS assessment inaccurately recorded the number of days injections and insulin were administered. Physician's orders and the Medication Administration Record showed that the resident received various injections on specific days, but the MDS assessment incorrectly indicated that injections were received on all seven days of the look-back period. Similarly, it inaccurately recorded insulin injections as being administered on all seven days, when they were only given on three days. This error was also confirmed by the Director of Nursing.
Failure to Develop Resident-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement resident-centered care plans for three residents, as required by their policy. Resident 36, who was cognitively impaired and had high blood pressure, did not have a care plan addressing his medication needs, despite physician's orders for Lopressor with specific parameters for administration. The Director of Nursing confirmed the absence of a care plan for this resident's high blood pressure management. Similarly, Resident 84, who was cognitively intact and required oxygen therapy due to heart failure, high blood pressure, and respiratory failure, lacked a care plan for his oxygen use. The Director of Nursing acknowledged this oversight. Additionally, Resident 85, who was cognitively impaired and diagnosed with PTSD from childhood trauma, did not have a care plan addressing her mental health needs. The Director of Nursing confirmed the lack of a care plan for her PTSD. These deficiencies were identified through clinical record reviews and staff interviews.
Latest citations in Pennsylvania
Failure to provide and document respiratory care: A resident with a trach had no documented evidence of respiratory rate, depth, and quality being monitored each shift and as needed, despite oxygen orders and trach care needs. Other residents with CPAP, nebulizer, and oxygen therapy had respiratory equipment left out of required storage, missing CPAP settings and care details in orders and care plans, and MAR entries signed by nursing staff even when respiratory staff reportedly completed the equipment changes.
Failure to Coordinate Hospice Services in Care Plans: The facility failed to coordinate hospice services with facility services for three residents receiving hospice care. One resident’s care plan did not include hospice needs despite hospice enrollment, and two residents’ comprehensive care plans lacked hospice agency contact information and access to the hospice 24-hour on-call system. The RNAC confirmed the omissions during interview; the residents had diagnoses including HTN, heart failure, kidney disease, diabetes, hypokalemia, and vitamin D deficiency.
Cross contamination occurred during a dressing change when an LPN placed a resident’s foot directly on the wheelchair seat without a barrier and did not clean the bedside table after the procedure. The facility also lacked infection surveillance documentation for several months, and its Legionella water management plan was incomplete, with no mapping of high-risk areas, no temperature logs, and no documented preventive measures for unused areas.
Failure to implement an antibiotic stewardship program. The facility’s infection control policy stated that antibiotic use protocols and a system to monitor antibiotic use would be part of the infection control program, but the Infection Control Program lacked documented evidence of antibiotic monitoring or review of appropriate antibiotic use for 3 months. The RN IP stated she had taken over the program, was also supervising the building, and had not been able to complete the program work or review the binders; administration confirmed the lapse.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's confidential medical information was left visible on the East med cart computer screen at the nurses station when the cart was unattended. An RN confirmed the observation and acknowledged that resident personal and clinical information was exposed to anyone passing by.
The facility failed to provide written bed-hold policy notice to two residents or their representatives during hospital transfers. One resident had HTN, kidney disease, and hypokalemia, and another had hyperlipidemia, CHF, and a right femur fracture; records showed hospital transfers, but no documentation that the required bed-hold information was given at the time of transfer.
Failure to monitor weight and individualize nutrition care plans: one resident did not have a required monthly weight recorded, despite facility policy requiring monthly weights by the 7th day of each month, and two residents had care plans that did not reflect their specific nutritional needs. One resident had dx including HTN, PVD, and a thyroid disorder with orders for a renal diet, mechanical soft texture, and Magic Cup BID, while another resident had documented significant wt loss, a regular lactose-free diet, and nutritional juice with meals. Staff confirmed the missing weight and the lack of individualized care plan interventions.
Unlocked treatment cart and improper medication storage were observed in multiple areas. An unlocked, unattended treatment cart was found in a hallway, and the East Medication Room contained personal items mixed with medication supplies. Opened Tubersol vials in two refrigerators and multiple opened meds in the A Hall and C Hall medication carts were not dated, and an LPN confirmed several of the findings.
Failure to Maintain a Qualified Infection Preventionist: The facility did not maintain a consistent qualified onsite IP responsible for infection prevention and control for one month after the former IP resigned. An RN assumed the role while also supervising the building, reported limited time to perform the duties, and could not produce a certificate for completion of the Nursing Home Infection Preventionist Training Course.
Failure to Provide and Document Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care was provided and documented for residents with tracheostomy, oxygen, CPAP, and nebulizer needs. Facility policy required respiratory treatments and equipment care to be based on physician orders, care plans, and diagnoses, and required documentation of services provided, including date, time, and the name and title of the person providing care. The respiratory therapy job description stated respiratory staff assumed primary responsibility for respiratory care modalities, conducted therapeutic procedures, maintained resident records, and documented patient care services. Resident R3 had diagnoses including traumatic brain injury and respiratory failure and had a physician order for oxygen at 10 liters per minute continuously, titrated to maintain oxygen saturation above 90%. The resident’s MDS indicated tracheostomy care was required. During observation, R3 was receiving oxygen via face mask to the trach and pulse and oxygen saturation were being monitored. However, review of the clinical record failed to show evidence that the resident’s respiratory rate, depth, and quality were monitored and documented each shift and as needed. Staff interviews confirmed that nurses were responsible for reviewing care plans, monitoring respiratory status, and documenting changes, and that the facility failed to document and monitor R3’s respiratory rate, depth, and quality each shift and as needed. Resident R67 had obstructive sleep apnea, heart failure, and diabetes, with an order for CPAP at hour of sleep at home settings. The order did not include the setting or any care for the CPAP machine, and the care plan also did not include the CPAP settings or care needed for the machine. During observation, the resident’s CPAP mask was sitting on top of the bedside stand and was not stored in a bag as required. Resident R69 had emphysema and was ordered albuterol nebulizer treatments four times a day, but during observation the handheld nebulizer was sitting on top of the machine and not stored in a bag as required. Resident R11 and Resident R32 both had oxygen therapy orders requiring nasal cannula changes every two weeks, but the MAR showed changes documented by nursing staff while interviews confirmed respiratory staff actually performed the changes and that staff signed off even when they had not personally completed the task. The interviews also reflected confusion about who was responsible for the equipment changes and documentation.
Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the end-of-life care needs of three residents. Review of the facility’s hospice policy showed that coordinated care plans for residents receiving hospice services were to include the most recent hospice plan of care and the care and services provided by the facility. For Resident R9, the record showed admission to hospice with a diagnosis of hypertensive heart disease, and the MDS indicated hospice care was received while a resident; however, the current care plan did not include a hospice care plan. During interview, the RNAC confirmed the facility failed to implement a care plan for Resident R9’s hospice needs. For Resident R24 and Resident R78, the records showed physician orders to admit each resident to hospice services. Their current comprehensive care plans did not include coordination details for hospice services, including contact information for the hospice agency or how to access the hospice’s 24-hour on-call system. During interview, the RNAC confirmed the facility failed to include this information in the plan of care and failed to ensure coordination of hospice services with facility services for these residents. Resident R24’s diagnoses included high blood pressure, kidney disease, and hypokalemia, and Resident R78’s diagnoses included high blood pressure, kidney disease, and vitamin D deficiency.
Cross Contamination During Dressing Change and Infection Control Program Deficiencies
Penalty
Summary
Cross contamination occurred during a dressing change for Resident R24. The resident was admitted to the facility and had diagnoses including peripheral vascular disease and diabetes. A physician order dated 4/27/26 directed the right lateral foot to be cleansed with normal saline, patted dry, treated with Santyl ointment, and covered with a dry dressing daily and as needed. During observation of the dressing change on 5/5/26, the LPN prepared a clean area on the resident’s over-bed table with a barrier and supplies, cleansed the foot, then placed the resident’s right foot directly on the wheelchair seat without placing a barrier before applying the ointment and dressing. After the dressing was completed, the LPN gathered and discarded supplies, removed the barrier from the over-bed table, and exited the room. During interview, the LPN confirmed that a clean barrier had not been placed on the wheelchair seat before the resident’s foot was placed there and confirmed that the bedside table was not cleaned after the supplies and barrier were removed. The LPN also confirmed the failure to prevent cross contamination during the dressing change. The facility also failed to maintain infection control surveillance for three months, as the infection control documentation did not show tracking of resident infections for February 2026, March 2026, and April 2026. When asked about the surveillance system, the RN who had taken over the program stated she had not done anything since taking over on 4/4/26 and had not looked at the infection control binders. The NHA confirmed the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for those months. In addition, the facility’s Legionella water management plan lacked mapping of high-opportunity areas, water temperature logs, and evidence of preventive measures for areas not in use, and staff could not provide logs or explain required temperatures during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for 3 of 10 months, specifically February 2026, March 2026, and April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that an antibiotic stewardship program would be part of the overall infection control program and that antibiotic use protocols and a system to monitor antibiotic use would be implemented. However, review of the Infection Control Program for February 2026, March 2026, and April 2026 found no documented evidence that antibiotic monitoring or review of appropriate antibiotic use was completed. During a telephonic interview on 5/6/26, the RN infection preventionist stated she took over the Infection Control program on 4/4/26, was also supervising the building, had only been looking at records for reportable issues, had not been able to do the program since starting, and had not seen the binders. Nursing home administration confirmed during an interview on 5/6/26 that the facility failed to implement an antibiotic stewardship program for those 3 months.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information on the East Medication Cart. Facility policy titled Quality of Life - Dignity, dated 1/6/26, stated that staff shall maintain an environment in which confidential clinical information is protected. During an observation on 5/4/26 at 11:38 a.m., the East Medication Cart at the nurses station was left unattended with the computer screen open, and identifiable resident personal and confidential information was visible to anyone passing by. During an interview at the same time, RN Employee E9 confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify the resident or the resident’s representative of its bed-hold policy for two hospital transfers. Facility policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would provide written notice explaining the duration of the bed-hold policy and information about the resident’s return to the next available bed, and that in an emergency transfer the notice would be provided within 24 hours. For Resident R24, who had diagnoses including high blood pressure, kidney disease, and hypokalemia, the record showed a hospital transfer on 3/31/26 and return on 4/5/26, but there was no documented evidence that written bed-hold information was provided at the time of transfer. For Closed Resident Record CR87, the record showed diagnoses including hyperlipidemia, congestive heart failure, and a right femur fracture. On 2/6/26, staff received venous doppler results indicating a nonocclusive thrombus in the right common femoral vein, relayed the results to the CRNP, and obtained orders to increase Eliquis temporarily and repeat an ultrasound. After the resident’s daughter called and staff reported the situation to the CRNP, the resident was sent to the hospital around 5:50 p.m. The emergency room transfer form and the clinical record did not include documented evidence that CR87 or the representative were provided written information about the facility’s bed-hold policy at the time of transfer.
Failure to Monitor Weight and Individualize Nutrition Care Plans
Penalty
Summary
The facility failed to properly monitor weight and nutrition status for two residents. For one resident, no monthly weight was recorded for April 2026, even though the facility policy required monthly weights to be obtained by the 7th day of each month and documented in the electronic medical record. That resident’s record showed diagnoses of high blood pressure, PVD, and a thyroid disorder, and the physician had ordered a renal diet, mechanical soft ground meat texture with a low fat diet for low protein, and Magic Cup twice daily for additional nutrition. A nurse aide confirmed that the monthly weight was not obtained. The facility also failed to individualize care plans to address resident-specific nutritional concerns for two residents. For one resident, the care plan identified potential nutritional problems related to dysphagia and the need for a mechanically altered and therapeutic diet, but it did not include resident-specific interventions for the ordered renal diet, mechanical soft diet, or supplements. For the second resident, the MDS indicated a 5% or greater weight loss in the last month or 10% or greater in 6 months, and the resident was not on a physician-prescribed weight loss regimen. That resident had orders for a regular lactose-free diet and nutritional juice with meals, but the care plan only included a general intervention to serve the diet as ordered and did not address the weight loss or the ordered diet and supplement needs. An RNAC confirmed the care plans were not individualized for these nutritional concerns.
Unlocked Treatment Cart and Improper Medication Storage
Penalty
Summary
The facility failed to properly secure a treatment cart while it was not in use and failed to properly store medications in the East Medication Room, the A Hall Medication Cart, and the C Hall Medication Cart. Facility policies reviewed indicated medication carts are to be kept closed and locked when out of sight of the medication nurse, and compartments containing drugs and biologicals are to be locked when not in use. The policy also stated that when opening a multi-dose container, the date opened shall be recorded on the container. During an observation on the East side, the treatment cart was found in the hallway near a room, unlocked and unattended. An LPN confirmed the cart had been left unlocked and unattended. In the East Medication Room, surveyors observed personal items and clothing stored with medication-related supplies, including cups, a tote bag, sweaters, pants, blankets, wheelchair cushions, and leg rest bags. The East first hall and second hall refrigerators each contained two opened vials of Tubersol solution that were not labeled with a date. In the A Hall Medication Cart, surveyors observed opened Nystatin liquid, Latanoprost eye drops, and a Trelegy Ellipta inhaler that were not dated, along with a coffee cup, pastry, sliced red peppers, and a personal cell phone in the cart compartment; an LPN confirmed the items belonged to her. In the C Hall Medication Cart, surveyors observed opened Robitussin cough suppressant, Milk of Magnesia, Miralax powder, and lactulose liquid that were not labeled with a date, and an LPN confirmed the findings.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a consistent qualified individual onsite who was responsible for implementing programs and activities to prevent and control infections for one of 10 months, identified as April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that the designated Infection Preventionist is responsible for oversight of the infection control program and serves as a consultant to staff on infectious diseases, resident room placement, isolation precautions, staff and resident exposures, and surveillance and epidemiological investigations. During interviews, Human Resource staff stated that the former Infection Preventionist resigned, with the last day of employment on 4/4/26. A Registered Nurse who took over the infection control program stated she assumed the role on 4/4/26, was also supervising the building, looked at records to see if any were reportable, and had not been able to fully do the work since starting, estimating about 12 hours per week. She also stated that her infection control training and certification had been completed long ago and she would need to find it. Review of the facility-provided certification courses showed training completed in 2022, but there was no certificate for completion of the Nursing Home Infection Preventionist Training Course. Nursing Home Administration confirmed the facility failed to designate a consistent qualified individual onsite responsible for infection prevention and control during that month.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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